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W. Philip T. James¹

¹London School of Hygiene and Tropical Medicine, London, United Kingdom.

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Medical conflicts of interests

We are all familiar with the need for our clinical judgement to be unbiased by vested interests. In this regard, the Unites States Food and Drug Administration now refuses to allow any doctors to be part of their review panels if they have had any financial support from a commercial company. The Swedish and more recently the Indian governments threaten doctors with the loss of their legal right to practice if they attend meetings sponsored by a company with financial interests in their field. Now, however, doctors need to be aware of other commercial interests directly responsible for the escalating epidemic of the noncommunicable diseases (NCDs) in the Middle East, including diabetes, hypertension and cardiovascular disease and most cancers as well as obesity. Thus medical as well as public health leaders in the Region need to become very active in developing both a tobacco-free society in the Middle East and a society where specific foods are no longer the primary drivers of NCDs among non-smokers.

Tobacco interests

The scourge of tobacco use is growing fastest in the Middle East (1,2) with the tobacco industry continuing to confuse, mislead and sabotage the efforts to reduce smoking rates despite the international legal requirement (3) to introduce tax, and other regulatory measures. The World Health Organization (WHO) has recently summarized the industry’s extraordinary, detailed, wide-ranging and multipronged efforts (4) (Box 1). Several countries in the Region are still heavily influenced by tobacco lobbying (5) with the recruitment of powerful people to their cause (6). Some countries are growing tobacco until now so alternative crops need to be heavily promoted and then tobacco production banned. The increasing use of social shisha smoking also still has to be tackled effectively.

Modern food promotion inducing the epidemic of NCDs

Although alcohol use is not a problem as found elsewhere in the world (7), the epidemic of NCDs in the Region has been driven by the significant increase in Western and fast foods as well as soft drinks/fruit juices which now dominate food outlets. This is coupled with the sharp decline in physical activity as everybody tries to buy a car and other mechanical aids to limit walking or physical work. Physical inactivity promoted by car manufacturers and all the manufacturers of computers and video entertainment is a more indirect problem; food is the main issue as even highly active people still develop the NCDs induced by poor diets.

Traditionally food choice has been an individual responsibility with nutrition education being seen as the appropriate means of helping people to choose a healthy “balanced diet”. This, however, is now seen to be a naïve and inaccurate analysis. Europe and the Unites States have subsidized their farming industry for decades with hundreds of billions of dollars annually to produce ever cheaper meat, butter, fats, oils and sugar. The food industry has also been subsidized to provide convenient food because so many women have gone out to work. So now many Western transnational agriculture and food companies have far greater incomes than most of the poorer countries in the world. Their duty is to increase profits for their shareholders even as their products replace traditional eating patterns and induce widespread ill health. The poorest in most societies have the highest NCD rates with a 20-year difference between the rich and poor in the age at which they are handicapped by NCDs because the poor eat the cheapest foods rich in total fat, trans and saturated fats, sugar and salt.

We now know that smoking, eating saturated fat from meat, butter and many oils (which induces high blood cholesterol levels), and salt (which leads to high blood pressure) are the main direct causes of cardiovascular disease. The Middle East problems are amplified by huge importations of poorly monitored fast foods with many governments subsidizing the importation and sale of cheap palm and coconut oil with their hazardous high saturated fat content. These inappropriate policies, coupled with intense industrial marketing, mean that food importers and retailers are profiting from the population’s ignorance and the lack of appropriate national preventive policies.

Many Middle Eastern countries now have the highest obesity and diabetes rates in the world apart from a few small island populations in the Pacific. No society can cope with these levels in health service, social or economic terms: the impact of early onset diabetes will escalate dramatically. Yet increasing sugar and total fat levels in the diet are now identified by WHO panels as inducing obesity (8–10) and hypertension (11) as well as dental caries (12,13). A UK government expert committee has also concluded that sugary drinks/fruit juices selectively induce diabetes (14). These products are marketed intensely, made available everywhere day and night with price manipulations dominating savage competition between retailers. They engage not only adolescents, as with tobacco and alcohol, but also focus on children as young as one year of age so that their taste and eating habits are established early.

WHO initiatives on food

Although WHO has called for a ban on marketing to young children, this has not been implemented in the Middle East. WHO-derived evidence now shows that the whole population, not just children, should be protected from these unwarranted manipulations. Dr Margaret Chan, WHO Director-General, recognizes that the food and soft drink industries are far more powerful than the combined efforts of the tobacco and alcohol industries and recently noted that “...it is not just Big Tobacco anymore. Public health must also contend with Big Food, Big Soda and Big Alcohol. All of these industries fear regulation, and protect themselves by using the same tactics…Research has documented these tactics well. They include front groups, lobbies, promises of self-regulation, lawsuits, and industry funded research that confuses the evidence and keeps the public in doubt” (15). So the challenge now is how to introduce a framework for government action to deal with the inappropriate food imports and foods available in the Region. We need to devise new taxation and regulatory measures which are similar to those for smoking while recognizing that we cannot be in the business of banning food as such. Therefore, we also need to develop integrated national systems which help farming and food businesses to flourish by producing high quality, low fat, very low sugary foods in an environment where currently overwhelming financial interests promote the very foods that ensure the NCD epidemic continues to escalate.

Conclusion

Medical leaders, familiar with the need for impartial evidence when dealing with drugs and new medical technologies, now need to recognize that they are confronted in the Middle East with other powerful vested interests, namely transnational tobacco and food industries.

These industries have easy access to the most powerful national political figures and work tirelessly to sabotage the necessary measures to control the epidemic in NCDs. The medical profession as well as those in public health has a major role to play in driving new governmental approaches to a tobacco-free society and an environment which effectively limits the marketing and provision of those foods responsible for the Region’s epidemic of NCDs.

Reference:

1. WHO report on the global tobacco epidemic 2013. Enforcing bans on tobacco advertising, promotion and sponsors. (http://www.who.int/tobacco/global_report/2013/en/, accessed 18 August 2014).
2. Golden Leaf Tobacco Co. Ltd [website] (http://goldenleaftobacco.net/index.php/media-library/news-a-events/99-middle-east-fastest-growing-region-for-cigarettes, accessed 18 August 2014).
3. World Health Organization. Tobacco Free Initiative. WHO Framework Convention on Tobacco Control [web page] (http://www.emro.who.int/tobacco/fctc/who-fctc.html, accessed 18 August 2014).
4. Tobacco industry interference. A global brief. Geneva: World Health Organization; 2012 (http://www.euro.who.int/data/assets/pdf_file/0005/165254/Tobacco-Industry-Interference-A-Global-Brief.pdf, accessed 27 August 2014).
5. WHO Regional Office for the Eastern Mediterranean, publications on the tobacco industry (http://www.emro.who.int/tobacco/publications/, accessed 18 August 2014).
6. World Tobacco Middle East [website] (http://www.worldtobacco.co.uk/middle-east/, accessed 18 August 2014).
7. Global status report on alcohol and health – 2014. Geneva: World Health Organization; 2014. (http://www.who.int/substance_abuse/publications/global_alcohol_report/en/, accessed 18 August 2014).
8. Te Morenga L, Mallard S, Mann J. Dietary sugars and body weight: systematic review and meta-analyses of randomised controlled trials and cohort studies. BMJ. 2013;346:e7492. PMID:23321486
9. WHO opens public consultation on draft sugars guideline. Note for the Media (http://www.who.int/mediacentre/news/notes/2014/consultation-sugar-guideline/en/, accessed 18 August 2014).
10. Hooper L, Abdelhamid A, Moore HJ, Douthwaite W, Skeaff CM, Summerbell CD. Effect of reducing total fat intake on body weight: systematic review and meta-analysis of randomised controlled trials and cohort studies. BMJ. 2012;345:e7666. 10.1136/bmj.e7666 [Review] PMID:23220130
11. Te Morenga LA, Howatson AJ, Jones RM, Mann J. Dietary sugars and cardiometabolic risk: systematic review and meta-analyses of randomized controlled trials of the effects on blood pressure and lipids. Am J Clin Nutr. 2014 May 7;100(1):65–79. PMID:24808490
12. Moynihan PJ, Kelly SA. Effect on caries of restricting sugars intake: systematic review to inform WHO guidelines. J Dent Res. 2014 Jan;93(1):8–18. PMID:24323509
13. Sheiham A, James WP. A new understanding of the relationship between sugars, dental caries and fluoride use: implications for limits on sugars consumption. Public Health Nutr. 2014 Jun 3;3:1–9. PMID:24892213
14. Scientific Advisory Committee on Nutrition. Scientific consultation: draft SACN Carbohydrates and Health report - June 2014 (http://www.sacn.gov.uk/pdfs/draft_sacn_carbohydrates_and_health_report_consultation.pdf, accessed 18 August 2014).
15. Chan M. Opening address at the 8th Global Conference on Health Promotion Helsinki, Finland 10 June 2013. (http://www.who.int/dg/speeches/2013/health_promotion_20130610/en/, accessed 18 August 2014).